Scotland’s Futures Forum Drug use and harm Dr. David Shewan Research Director Glasgow Centre for the Study of Violence Glasgow Caledonian University Drug use and society Psychoactive drug use - including alcohol and tobacco is widespread within most societies. Problems associated with drug use, and particular drugs, are primarily focused upon health and crime: these can seriously and tragically affect the individual user, family, friends, loved ones. Drug problems can affect local communities, criminal justice systems, health services, employment and economic productivity; at a global level the illegal drug trade can have a negative impact on entire countries. Drug Use and Society Most drug use is relatively nonproblematic, causing little harm to self and/or others. This involves a number of protective factors, ranging from personal to societal. A distinction, albeit not straightforward, can be made between ‘controlled’ and ‘addicted’ use. A Scottish newspaper, 14/7/07 I OVERDOSED ON 14 CUPS OF ESPRESSO DEALER'S BABY PLEA IS REJECTED CRUEL DRUNK KILLED PUPPIES TEETOTALLERS GET STONED ROBIN WILLIAMS: BACK ON THE WAGON DESPERATE: SCOTLAND’S POOREST KIDS A Scottish newspaper, 17/06/06 ‘Homophobic thugs’ jailed for 28 years over murder Two army psychiatric casualties every day in Iraq Wife-killer dies in prison Suspect charged in shooting incident Boy held over woman’s death Pub glass ban ‘could make drinking more dangerous’ Hunt after ‘sleeping girl’ seen locked in car boot Girl, 3, targeted by paedophile in McDonalds Domestic abuse helpline calls soaring Same Scottish newspaper, same day… Good response to appeal over schoolgirl attacks Eight-year-old among 500 Scots children in drugs rehab Golden eagle found poisoned with banned pesticide bait on Deeside Youngest mother to be taken into care Bomber hid explosive in his shoe Slums spread as more people become city dwellers Pentagon excludes press from Guantanamo Snipers claim four more killings Ship evacuated after bomb hoax Wife’s severed head found at crash site The relationship between risk, drug user, drug use, and drug-related outcome is heterogeneous and complex Perceived risk (User) Drug Physical harm Dependence Social (economic) harms Enjoyment Relaxation Stimulation The Medical Model of Substance Addiction Assumes detrimental effects to the individual and society. Assumes that drugs do things to people and make them behave in certain ways. Psychological factors are seen as secondary, and social and cultural factors are mainly just referred to. Treatment is usually necessary to stop further deterioration. Drug, Set, and Setting DRUG - the pharmacological action of the substance. SET - underlying and learned psychological aspects of the user (and the influence of genetic and biological characteristics). SETTING - situational factors, and the wider social and cultural context. Set Many problematic drug users also have (other) mental health problems. These could be underlying health problems, they could be exacerbated by problematic drug use, they may be the result of problematic drug use. There is strong and increasing evidence that many problematic drug users are seriously traumatised (c.f. The Barlinnie Project). Can you pass the Acid Test… “On Becoming a Marijuana User” (Becker, 1963). Arguably one of the earlier modern day examples of harm reduction advice: To learn how to take the drug; to recognise the effects; to interpret the effects as pleasant. Becker also applied these principles to LSD use in the 1960s. As predicted, after an initial flurry of ‘novice’ LSD users entering hospital, these numbers drastically reduced. Set - in denial? A paper by Phillip Murphy, Liverpool John Moores University presented data from 328 ecstasy users and reported that ‘even’ after two years regular use most still felt positive about the drug’s effects and wished to keep using for this reason. His conclusion: “It is likely that some users come to prefer the person they are, and the world they experience, under the influence of the drug. This may be seen as a form of psychological dependence, even though they are not physically addicted to it” (Quoted in The Observer, 2004). At the top of the hierarchy of harmful drugs of misuse… heroin. “The opiates are drugs of addiction… anyone who takes an opiate for a long enough time will become addicted.” (Edwards, 1984). Although… “People who use heroin are highly disposed to having serious personal and social problems before they touch heroin… heroin is a ‘worse’ drug only because ‘worse’ people use it.” (Robins, et al. 1980, 2005). At the top of the hierarchy of harmful drugs of misuse… heroin. And it has been argued… “Their [addicts’] heroin use is anything but an escape from life. They are actively engaged in meaningful activities seven days a week. They are always on the move and must be alert, flexible and resourceful.” (Preble and Casey, 1969). “Some patterns of heroin use can be non-intrusive to the user and society. A more integrative theoretical understanding of drug use does not rest on assumptions about the causal effect of simply taking a particular drug [heroin]” (Shewan and Dalgarno, 2005). Setting The Rat Park Experiments (Alexander, et al., 1994) These involved creating an environment in which to carry out these experiments which in an experimental psychology context closely resembled as practically possible a ‘natural environment’. As described by Alexander (1994): “Rat Park, as it came to be known, was airy and spacious, with about 200 times the square footage of a standard laboratory cage. It was also scenic, (with a peaceful British Columbia forest painted on the plywood walls), comfortable, (with empty tins, wood scraps, and other desiderata strewn about the floor), and sociable (with 16-20 rats of both sexes in residence at once).” [p.24]. Setting “Nothing that we tried instilled a strong appetite for morphine or produced anything that looked like addiction in rats that were housed in a reasonably normal environment.” [p.27]. Crack Babies Long-term [American] research with crack babies has indicated that these children are impaired, however this impairment has little to do with prenatal cocaine exposure and a lot to do with social exclusion – most crack babies have heard gunshots by age 7. Such findings are unpopular for many obvious reasons – poverty is harder to tackle, less easy and popular to campaign against, than drug use (Stanton Peele, website). Shewan and Dalgarno, (2005) – Controlled Heroin Use Participants were recruited through social networks and must have: Illicitly used opiates at least ten times in each of the preceding two years. Never been in treatment for any drug (including alcohol). Never served a custodial sentence. 126 people living in Glasgow. 75% were male, 25% female, the mean age was 28.5 years. SES, Education, and the general population Occupational status (I = highest) SES category I II III IV V Heroin sample 9% 29% 53% 9% 0% UK population 5% 23% 48% 18% 6% At the time of the study, levels of the population currently in higher education in Scotland, was recorded at 47% of the general population (Universities Scotland, 2001). There were no significant differences between the controlled heroin use sample and the general population on either of these variables – possibly the most important finding in the study. Opiate Drug heroin codeine opium methadone Ever used 124 (98%) 101 (80%) 84 (67%) 69 (55%) Average No. days used last two years Mean – 167 Median - 50 Mode - 25 Mean - 28 Mode - 0 Mean - 7 Mode - 0 Mean - 31 Mode - 0 Mean years used Mean age first use 7 21 7.5 21 9 22 5 24 Non-opiate Drug Alcohol n ever used 126 (100%) Cannabis 126 (100%) Amphetamine 124 (98%) Ecstasy 124 (98%) Benzos 106 (84%) Cocaine 122 (97%) Crack 39 (31%) Mean Mean age amount first used per use session 14 10 units 15 1.5g 17 2g 21 1.5 pills 19 3 pills 20 1g 25 1 rock Cocaine 65% of those who had used cocaine had used it in the six months prior to interview The mean years of use for cocaine was 8 years 52% of those who had used cocaine had used it with opiates; the main reason being to ‘enhance the effects’ of both drugs. Availability and motivation 84% of the sample reported that for them heroin was ‘very easy’ or ‘easy’ for them to obtain. 98% of the sample rated heroin as ‘very enjoyable’ to use. These questions weren’t asked about cocaine, but… Injecting and sharing 25% had ever injected; 15% had injected within the two years prior to interview. Ongoing regular injecting was confined to 5% of the sample. 10% had ever shared injecting equipment; 3% had shared in the two years prior to interview. No participant had tested positive for HIV. One participant had tested positive for hepatitis C. Research outcomes At the conclusion of the study, 7% (6/85) of the follow-up sample had entered specialist treatment for their drug (heroin) use. No participant had died. No participant was serving a custodial sentence. One participant had gone to Amsterdam, had a sex change operation (and seemed happy enough). Implications Drugs assumed to be addictive may not necessarily be used in an addicted way (e.g. heroin, cocaine). Drugs assumed to be harmful may not be necessarily so. Drugs assumed to drive criminal behaviour may not necessarily do so. Researchers require to collect data from ‘hidden’ populations and not rest primarily on assumptions about the causal effects of simply taking a particular drug. Drug, Set, and Setting Acknowledges the complexity of drug use and addiction; provides a model for comparing factors associated with problematic versus non-problematic drug use. It is a valid framework to predict and explain, for example, controlled versus addicted heroin use. A medical approach Can be overstated. But, it can be argued, has a range of practical values - an improvement in treatment and interventions; more sympathetic approach from family, employers, the criminal justice system. But does a focus on ‘drug’ help in this respect? Drug, set, and setting Acknowledges the complexity of drug use and addiction. Provides a model for comparing factors associated with problematic versus nonproblematic use of particular drugs. As a theory it requires appropriate sampling. It is a useful framework to predict and explain, for example, controlled heroin use. Or, chaotic use of [name drug]. Visible harms, unobtrusive users Typically, controlled drug users have jobs, are well-educated, and are law-abiding and productive members of the community. They also happen to use a lot of drugs, including the most harmful. But as drug users, they were indeed unobtrusive. So, what would be the ethics of criminalising this group because of their drug use? Would this be the greater harm? So what do you do…? Help people with problems, including their problems with drug misuse; provide the full range of treatment and care options. Education, prevention, harm reduction. Generally, leave people alone who seem okay, and don’t have problems with the drugs they use. From whatever angle, what use the Misuse of Drugs Act? The Delphic System Your expert views please, on… Smoking it [heroin], right, you’ll maybe just get a little buzz, but if you inject it then you’re ‘phewww bingoed!’ So then, of course if they tried smoking it and they’re not getting their hands on enough of it, which they probably arenae, then they try injecting it like ‘whoa what a difference!’, ken?. So then they’re injecting it. Why? Because it works better than smoking it. You understand what I mean? [male prisoner].